Healthcare Provider Details

I. General information

NPI: 1750177523
Provider Name (Legal Business Name): KAYSHA JEAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DATES DRIVE CAYUGA MEDICAL CENTER
ITHACA NY
14850
US

IV. Provider business mailing address

INTERNAL MEDICINE RESIDENCY CAYUGA MEDICAL CENTER 101 DATES DRIVE
ITHACA NY
14850
US

V. Phone/Fax

Practice location:
  • Phone: 607-252-3457
  • Fax:
Mailing address:
  • Phone: 607-252-3457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: